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Insurance and Forms

The Atos Medical Insurance and Reimbursement Team is committed to helping you navigate through the process to make it as smooth and easy as possible, getting the most from your benefits.  We will file claims for durable medical equipment (DME) orders.

We are also working to get in-network with more and more insurance companies which can mean easier access to products and better reimbursement options for you!  Click here for the latest list and check back often!

For an insurance claim to be filed, we need the following to be completed and returned to our office:

  • Front and back copies of all insurance cards
  • Prescription/Diagnosis Form (including frequency of replacement)
  • Patient Insurance Information (PIIF) Form
  • Patient Service Agreement (PSA) Form

The type of DME equipment ordered, laryngectomy supplies or jaw motion rehabilitation supplies, will determine which forms are to be completed.

Prescription / Diagnosis Forms - Laryngectomy
  • Must be completed by treating physician
View Document
Prescription / Diagnosis Forms - Jaw Motion Rehabilitation
  • Must be completed by treating physician
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Health Insurance Portability and Accountability (HIPAA) Information - Notice of Privacy
  • This notice describes how medical/health information may be used/disclosed and how it can be accessed.
View Document
Health Insurance Portability and Accountability (HIPAA) Information - Acknowledgement of Receipt
  • This notice describes how medical/health information may be used/disclosed and how it can be accessed.
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Medicare Compliance Form
  • An affirmative statement by the Medicare beneficiary instructing Atos Medical not to file a claim to Medicare on the beneficiary's behalf when purchasing durable medical equipment, L8509, indwelling voice prosthesis. The beneficiary does not desire a Medicare claim to be filed and therefore understands there is no further appeal for payment.
View Document
Medicare Provider Enrollment, Chain of Ownership System (PECOS)
  • For any durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items to qualify for coverage by Medicare it must be ordered by a physician or a practitioner who is eligible to order such item.
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DMEPOS Supplier Standards
  • CMS Medicare DMEPOS Supplier Standards
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Insurance Questions and Answers
  • General Medicare and Private Insurance Q&As
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Ordering Supplies - Larygectomy
  • Instructions for ordering supplies
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Ordering Supplies - Jaw Motion Rehabilitation
  • Instructions for ordering supplies
View Document
Patient Bill of Rights and Responsibilities
  • Information about your rights as a patient
View Document